UK FASHIoN RCT

Full randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care

Professor Griffin led the largest ever randomised control trial of hip arthroscopy, and the first to demonstrate the benefits of the surgery for people with femoroacetabular impingement syndrome.

UK FASHIoN (Full trial of Arthroscopic Surgery for Hip Impingement compared with coNservative care) was commissioned by the UK National Institute of Health Research, the R&D arm of the National Health Service, with a budget of almost £2M. It was prompted by the need to provide an evidence base for the increasing use of hip arthroscopy in the UK (a need that is felt around the world), and was designed to compare the clinical and cost effectiveness of hip arthroscopy with ‘best conservative care’.

In UK FASHIoN we recruited 348 patients from 23 hospitals across the UK. The surgeons were all providing a hip arthroscopy service, and the physiotherapists delivering personalised hip therapy (PHT) were specially trained to do so. All of the patients had FAI syndrome, as defined by the Warwick Agreement, and all were randomised to either hip arthroscopy or PHT. This was a pragmatic trial, so we knew and accepted that some people might not get the treatment they were allocated to, that there might be delays in treatment, and that some patients might not follow all our advice. It is best to think of a pragmatic trial like this as being a test of the best strategy: When you decide upon which strategy to recommend to a patient in clinic, which will result in the best outcome, taking into account all of the problems and friction which occur in everyday clinical practice?

“...there was a greater improvement in those allocated to hip arthroscopy than PHT, with a mean difference of 7 points (p=0.009) in favour of surgery”

UK FASHIoN RCT Results

So, what did we find? In both groups, patients’ hip related quality of life increased, measured by iHOT-33 one year after randomisation. Mean iHOT-33 scores improved to 59 in the arthroscopy group and 50 in the PHT group. After adjustment for potential confounders, there was a greater improvement in those allocated to hip arthroscopy than PHT, with a mean difference of 7 points (p=0.009) in favour of surgery. This is statistically significant, but is also greater than the minimum clinically important difference of the iHOT-33, so patients will notice and care about it. This might not seem like a big difference, but remember that this is an average benefit of surgery, compared with a really good conservative care package. When you combine this with the real-world challenges of a pragmatic trial, which tend to dilute the effect, we can be very confident that surgery provides real benefit in most of our patients.

“The study by Griffin and colleagues is the first to establish the efficacy of hip arthroscopy versus physical therapy in the medical literature.”

Karen K BriggsThe Lancet

UK FASHIoN was published in The Lancet in June 2018, one of the leading medical journals in the world. You can download a copy of the article here.

A podcast of Professor Griffin talking to Karim Khan, the editor of the British Journal of Sports Medicine, about the study and what it means for people with hip pain, can be downloaded here.